Open Heart (51 page)

150
   
In another study:
“Adherence to Treatment and Health Outcomes,” by R. I. and S. M. Horwitz, in
Archives of Internal Medicine
153 (1993), pages 1863–1868, cited in Harrington, page 42.

155
   
On the cover: “A
popular operation for arthritis of the knee worked no better than a sham procedure in which patients were sedated while surgeons pretended to operate,” the
New York Times
reports on July 11, 2002 (“Arthritis Surgery in Ailing Knees Is Cited as Sham,” by Gina Kolata). Each operation, “more than 650,000” of which “are performed each year,” according to the article in the July 11, 2002, issue of
NEJM
(J. Bruce Moseley et al., “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee,” 347:2, pages 81–88), costs roughly $5,000. The study's conclusion: “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.” See also the accompanying editorial in
NEJM
, pages 132–133.
“that the placebo effect”:
Talbot,
New York Times Magazine
, January 9, 2000, pages 34–39, 44, 58–60.

156
   
“It may seem strange”:
Leston Havens,
A Safe Place: Laying the Groundwork of Psychotherapy
, page 88.

156
   
In talking:
In “Disease and Illness” (
Culture, Medicine and Psychiatry
, vol. 1 [1977], page 11), Leon Eisenberg explains the difference this way: “illnesses are
experiences
of disvalued changes in states of being and in social function; diseases, in the scientific paradigm of modern medicine, are
abnormalities
in the
structure
and
function
of body organs and systems.”
“the history of medical treatment”:
Arthur Shapiro, “The Placebo Effect in the History of Medical Treatment (Implications for Psychiatry),”
American Journal of Psychiatry
116 (1953), pages 298–304, cited in Jackson, page 281.

156
   
Some researchers:
Regarding skepticism about the placebo effect, see Gina Kolata, “Placebo Effect Is More Myth Than Science, Study Says,”
New York Times
, May 25, 2001; and Richard A. Friedman, “Can the Placebo Treat Depression? That Depends,”
New York Times
, June 25, 2002.
“no evidence”:
Howard Spiro, “Clinical Reflections on the Placebo Phenomenon,” cited in Harrington, pages 37–55 [49, 50, 51, 53]. Spiro distinguishes between placebo
response
(“behavioral change in the person receiving the pill”) and placebo
effect
(“change attributable to the symbolic effect of the medication”) (page 49).

158
   
“the astonishing total”:
Shapiro, “The Placebo: Is It Much Ado About Nothing?” in Harrington, page 13. The quotations from Galen are also on page 13.

159
   
“these issues”:
Jackson, page 31.

159
   
For the doctor:
Regarding
philanthropia
and
philotechnia
, see Pedro Lain Entralgo,
Doctor and Patient
, trans. Frances Partridge, pages 21–22. Citing Entralgo's text (page 40), Jackson says that Entralgo “has argued that friendship (
philia
) was the cornerstone of the doctor-patient relationship in the ancient world (pages 17–29); and he goes on to reason that, in one form or another, it continued to be a crucial element in the art of healing during subsequent centuries.”

Jackson also emphasizes what my friends emphasize: the importance of attentive listening. The kind of attentiveness to the patient that inspired confidence and healing several thousand years ago, Jackson argues, does the same in our time, and not only, or primarily, because such attentiveness can bring comfort and relieve pain, but for clinically pragmatic reasons.

“Turning to the context of a general physician's consultation room,” he writes,

we find proof that attentive, interested listening can turn an inchoate litany of complaints into a gradually coherent story of distress and discomfort. The patient has been the better for having told the doctor, whether it has been a confessing, a confiding, a catharsis, or a revealing of physical symptoms that would have otherwise gone undetected; and the doctor has been the better for having been
with
the patient in a healing endeavor rather than having rapidly gotten rid of him or her with the aid of a prescription pad. Often enough, the physician's listening has allowed the emergence of more private concerns and symptoms which have been the issues that were more crucially in need of therapeutic attention, (page 92)

Like my friends, Jackson does not want anyone to get “the mistaken idea” that “healing is nothing but a matter of employing psychological factors to influence sufferers toward better health.” He does, however, “wish to emphasize that these factors will frequently not be sufficient, but that they will very frequently be necessary” (page 391).
In a series:
David Mechanic's work on trust is summarized in “The Importance of Trust in Medical Care: Papers and Publications by David Mechanic, Ph.D.; Executive Summary,” in the Robert Wood Johnson Foundation's
Author Series
1:12 (April 2000).

160
   
“Frustrations”:
Jerome P. Kassirer, “Doctor Discontent,”
NEJM
339:21, pages 1543–1545 [1543]. “It is difficult, however,” Mechanic comments,
“to assess how much this chorus of complaints reflects physicians' anxieties about control over their professional lives and future incomes and how much it reflects deficiencies of current medical care.” This quotation is in “The Managed Care Backlash: Perceptions and Rhetoric in Health Care Policy and the Potential for Health Care Reform,”
Milbank Quarterly
79:1 (2001), pages 35–54 [40].

160
   
“The public has”:
Mechanic, “The Managed Care Backlash,” pages 37, 38, 47

161
   
“It is not merely”:
Leon Eisenberg, “The Search for Care,”
Daedalus
(1977), pages 235–246 [236–237]. Neither cost nor access “explains away the paradox that although we know the ‘old family doctor' had almost no decisive remedies to offer for serious disease,” Eisenberg writes, “we nevertheless lament his disappearance.”

“The potency of the witch-doctor's pharmacopoeia may not have matched ours,” he continues, but “he gave a name to what had been mysterious, he offered an explanation for its cause, he prescribed a ritual for its exorcism, and he legitimized dying. At the least, the patient felt less alone; at best he was restored to his former health.”

163
   
“swung back and forth”:
Jackson, page 391. Part of the reason for the priority given to medical biotechnology is economic. John Lantos, a pediatrician who was a member of President Clinton's Health Care Reform Task Force, comments: “From the perspective of hospital budgets, the best treatments have been those that require long and intense hospitalizations: heart surgery, transplantation, cancer chemotherapy, neonatal intensive care. In these cases, one needs lots of technology, lots of people, and lots of money, and it all goes toward intervention in a crisis for an identifiable patient.”

“Subtle, preventive treatments don't capture our imaginations,” he goes on, “don't commandeer the same resources, and those who provide such treatments are thus much more peripheral to this modern medical enterprise.” These remarks are from his eminently sensible book,
Do We Still Need Doctors?
pages 79–80.

163
   
End-of-life care:
See Horton, “In the Danger Zone,” page 34; Robert J. Blendon and John M. Benson, “Americans' Views on Health Policy: A Fifty-Year Historical Perspective; Because Americans' views conflict, policymakers must be cautious about interpreting the public's mood based on isolated public opinion questions,” in
Health Affairs
, March-April 2001; Christopher Hogan et al., “Medicare Beneficiaries' Costs of Care in the Last Year of Life,”
Health Affairs
, July-August 2001; Anne A. Scitovsky, ‘“The High Cost of Dying' Revisited,”
Milbank Quarterly
72:4 (1994); and James D. Lubitz and Gerald F. Riley, “Trends in Medicare Payments in the Last Year of Life,” a Special Article in
NEJM
328:15 (April 15, 1993), pages 1092–1096.

163
   
Rich says:
Rich, who has taught at several medical schools, would eliminate most of the basic science courses that dominate the first two years of training, starting with the dissection of cadavers. “Pathology, psychology, biochemistry—these courses are fairly worthless, since you learn what you need to know about them as you go into the various specialties of clinical medicine,” he says, “and then you learn them in a much more pragmatic way.”

164
   
“these innovations”:
The reasons Mechanic advances for the importance of effective communication merit repeating: “Effective communication allows the physician to understand the patient's expectations and concerns; to obtain accurate information, thereby facilitating diagnosis; to plan and manage the course of treatment; and to gain the patient's understanding, cooperation, and adherence to treatment.” See “Public Trust and Initiatives for New Health Care Partnerships,”
Milbank Quarterly 76:2
(1998), pages 281–302 [281]. Quotes in text from pages 298, 281, 282.

166
   
Jerry pauses:
Regarding the debts incurred by medical students, see “Removing Career Obstacles for Young Physician-Scientists—Loan-Repayment Programs,” by Timothy J. Ley and Leon E. Rosenberg, in the “Sounding Board” section of
NEJM
346:5 (January 31, 2002), pages 368–371. According to the article, “The late bloomers are most likely to incur debt during medical school. Only 17 percent of all medical students graduate free of debt. For the class of 2001 overall, the average debt was more than $99,000. Among students in private medical schools, the average debt was nearly $119,000, and one third of this group had debts that exceeded $150,000” (page 369).

167
   
‘“sick-man”‘:
Nicholas Jewson, “The Disappearance of the Sick-Man from Medical Cosmology,”
Sociology
10 (1976), pages 225–240 [229], cited by Jackson, page 61.

167
   
“began to take shape”:
Jackson, page 61.

168
   
Such changes:
Kevin Patterson, “What Doctors Don't Know (Almost Everything),”
New York Times Magazine
, May 5, 2002, pages 74, 76–77.

168
   
“As the scientific mode”:
Jackson, page 62.

168
   
“In effect”:
Weatherall, page 57.

168
   
In
Time to Heal: For Kenneth M. Ludmerer's account of the rise of a “separation of functions” between “clinician-teachers” and “physician-scientists,” see
Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care
, pages 288–295.

169
   
“carried negative implications”:
Ibid., page 361.

169
   
“to revert”:
Ibid., pages 381, 383, 389.

170
   
“Is this the best”:
Weatherall, page 328.

171
   
“The contemporary disarray”:
Daniel M. Fox,
Power and Illness: The Failure and Future of American Health Policy
, pages 1,323. “As Daniel M.
Fox has discussed,” Ludmerer writes, “in the era of chronic diseases, the system of health care financing and delivery remained based on an acute disease model. Thus, third party payers would often pay for renal dialysis but not for the outpatient treatment of high blood pressure that could have prevented the kidneys from failing in the first place” (page 286).

172
   
We currently spend: Crossing the Quality Chasm: A New Health System for the 21st Century
, Institute of Medicine (Washington, DC: National Academy Press, 2001). The figures on chronic care are from
Chronic Care in America: A 21st Century Challenge
(August 1996), prepared by the Institute for Health and Aging, University of California, San Francisco, for the Robert Wood Johnson Foundation, Princeton, New Jersey.

173
   
“The resistance”:
Fox, page 88.

174
   
Sometimes, it seems:
“In the second half of [the nineteenth] century, the growing perception that the threat of infection was receding coincided with the ascendancy of new theories for understanding disease and intervening to prevent and treat it,” Daniel Fox writes. “Most important, the great advances in bacteriology in these years led to the concept, in the words of a classic study of human disease, that ‘each human ailment must have a singular and specific cause.'” Fox's quotation is on page 23; the quotation about each human ailment having a singular and specific cause is from M. S. R. Hutt and D. P. Burkitt,
The Geography of Non-Infectious Disease
, page 1.

174
   
“It is the sheer”:
Weatherall, page 322.

174
   
“it is not information”:
Nuland, “The Proper Dosage of Judgment,” New
York Times
, July 10, 2000.

175
   
More:
See, for example, “Geographical Mobility: Population Characteristics,” March 1999 to March 2000, or “Why People Move: Exploring the March 2000 Current Population Survey (Special Studies),” March 1999 to March 2000.

175
   
at this writing:
Figures for the exact number of uninsured Americans vary, but generally are estimated at being between 39 and 45 million. A
New York Times
article claims that, according to government figures, “the number of uninsured Americans remains at 39 million” (“Paralysis in Health Care,” May 29, 2002), though two years earlier, the government, using a different method of calculating this figure, stated that the number of uninsured was 44.3 million (“Still Uninsured, and Still a Campaign Issue,” by Robert Pear, New
York Times
, June 25, 2000). On September 30, 2002, the Census Bureau stated that the number of uninsured was 41.2 million, or 14.6 percent of the population. New
York Times
, September 30, 2002, “After Decline, the Number of Uninsured Rose in 2001,” by Robert Pear.